UFCW patients: yes we take your new insurance!

Effective 9/1/09, UFCW & Employers Benefit Trust (UEBT) and UFCW Northern California and Drug Employers Health and Welfare Trust Fund (Valley Drug Fund) will change from Anthem Blue Cross PPO to Blue Shield of California PPO.

We accept both of these insurances, so this change will not effect your health care at our office. All we ask is that you let us make a copy of your new card whenever we next see you.

The Influence of Health Insurance Companies on Health Care Reform

This is a link to a fascinating interview by Bill Moyer of Wendell Potter. Mr. Potter was employed as a Vice-President of Public Relations for Cigna, which is one of the largest health insurance companies in the US. Was, that is, until a bit of an eye-opener when he was back in Tennessee visiting family.

...we shouldn't fear government involvement in our health care system. That there is an appropriate role for government, and it's been proven in the countries that were in that movie.

You know, we have more people who are uninsured in this country than the entire population of Canada. And that if you include the people who are underinsured, more people than in the United Kingdom. We have huge numbers of people who are also just a lay-off away from joining the ranks of the uninsured, or being purged by their insurance company, and winding up there.

BILL MOYERS: You told Congress that the industry has hijacked our health care system and turned it into a giant ATM for Wall Street. You said, "I saw how they confuse their customers and dump the sick, all so they can satisfy their Wall Street investors." How do they satisfy their Wall Street investors?

WENDELL POTTER: Well, there's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.

I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

The link is to a video, and also to a viewable and printable full transcript.

Check it out, if you are interested to understand how commercial insurance companies influence the discussion and the political process around the reform of our health care system.

Tylenol, Vicodin and Percocet safety

If you follow the news much, you will be noting that an advisory panel to the Food and Drug Administration (FDA) is expressing concerns about the safety of two commonly prescribed narcotic "pain-killers" Vicodin and Percocet, and also about the safe dosing levels for Tylenol (generically known as acetaminophen).

Just to clarify, the issue is not so much about the maximum safe doses of acetaminophen so much the fact that it's in a number of prescription and over-the-counter medications and that it may be easy for people to accidentally take too much as they may not realize how much they are actually taking.

Acetaminophen is in "non-aspirin pain relievers" over the counter, and in Tylenol as regular,
Extra-Strength and Arthritis. It is also in a large number of generic and Tylenol brand cough and cold formulas, allergy medicines and sleep aids.

In addition to this, it is a component of Vicodin and Percocet which are prescription medicines for pain.

You can start to see where it might be easier than you suppose to get more acetaminophen into you than you thought. This Q&A rather sums it up:

People think that if it’s a safe drug and I have this pain, it works better if I take more,” said Cesar Alaniz, a clinical associate professor at the University of Michigan College of Pharmacy.

How Do Drugs Get Tested?

The recent news about over-the-counter (OTC) Zicam causing a loss of sense of smell in over 300 people raises a few eyebrows. Frankly, Bextra being withdrawn in 2005 for being linked to causing an increase in heart attack risk raised quite a few eyebrows, too.

It's important to make a distinction between pharmaceuticals and supplements.

Pharmaceuticals are regulated and approved by the Food and Drug Administration (FDA) and must be proved to be safe as well as effective in treating the condition for which approval is being sought.

Supplements, herbs and vitamins are marketed as nutritional or dietary supplements and therefore are not required to meet any such standards. Let the buyer beware!

By the time a pharmaceutical has received FDA approval to be sold, it has been researched and extensively tested in labs and then in humans for both safety and effectiveness. The testing in humans usually involves several thousands of folks, half of whom receive the tested drug and the other half a placebo.

This is done in such a way that the doctor giving the drug doesn't know whether the person will receive an active drug or a placebo. This is called randomized, double-blind placebo/control study, and is intended to keep people from reporting or not reporting side-effects because they know beforehand whether they got drug or placebo. Also, it is done this way so the doctor cannot reveal whether they are getting drug or placebo, either.

Granted, this assumes that the drug manufacturer is conducting the research in accordance with standards, and isn't "massaging the data". It also assumes that the directorship of the FDA is aggressively pursuing its mandate on behalf of the public.

In the case of Bextra, the drug company reported 11 months of heart attack data as a full year, thereby under-reporting the incidence of heart attacks related to the drug to the FDA.

Also note that the burden of proof of effectiveness and safety is on the company, and not the FDA. This is as it should be from the point of view that the costs of such proof should be on the company which stands to profit from FDA approval, and should not be upon the consumers and taxpayers.

Also, it is important to realize that if a drug as a rare side-effect and perhaps only occurs in one out of 10,000 or 50,000 people who take it, this is not going to become evident until several million people have taken it. This is neither a failure of the drug company, nor the FDA. This is simply a fact of life, which is why there are processes for reporting potential rare but serious side-effects with medicines. An example of this is the current investigation of psychiatric side-effects with the new smoking cessation drug Chantix.

Bottom Line:

Supplements and herbs differ from pharmaceutical drugs significantly in that they are not required to be proven to be safe or effective, nor to be tested for interactions with medicines or foods, nor for truth in labelling.

This does not mean that they do not work or should never be taken, but it does mean that a reasonable degree of skepticism in the literal sense should be exercised.

A trial period of changes in hospital coverage: and now for something completely different!

Short story:

Starting Monday July 13th, for a trial period through the end of October, my call group will have patients admitted and cared for by the hospital's hospital-based doctors for 3 weeks on and 3 weeks off. We will care for our patients for 3 weeks off and 3 weeks on, alternating with the hospital-based docs.

At the end of this trial period, we'll see how it's been working out for everyone, including our patients to see if we all want to continue on in this 3 weeks on/3weeks off cycle.

Long story:

Physicians used to be on-call for the needs of their patients 24/7/365. Naturally, that gets old pretty quickly since you can never be away from a phone our out of the area.

A few decades ago, a common practice developed where different doctors would agree to share coverage on evenings, weekends and holidays. When you are on-call you're on for the group, but when you're off you're all the way off (as in you can go fishing or skiing, leave town, catch a movie with your kids...).

In the past 5 or so years, a nationwide trend which Marshall adopted is one in which family doctors only see patients in the office, and the hospital hires doctors who only see patients in the hospital (such doctors are referred to as hospitalists). Supposedly, the patients get better care as they are seen by doctors who only ever treat hospitalizably ill people. Also, supposedly this is more profitable for both the family docs and the hospital.

So far, no one including Marshall can demonstrate a difference in hospitalist versus family doctor care in terms of the complexity of the patients, how well they do and how long they have to stay in the hospital.

Unfortunately, one outcome of this is that there are only 7 primary care docs in Western El Dorado County who still see patients in the office and also in the ER and in the hospital. Marshall's own doctors backed out of the hospital about 5 years ago and can't come back.

I share call with Drs. Keith Boston, Leanne Camisa and Dave Ramos. This means if you have to be in the hospital after hours, one of us will be admitting you and I will see you first thing in the morning (or on Monday AM, if it's a weekend).

Thing is, Camisa and Ramos are married and have two young children. As you can imagine, they are finding it increasingly difficult for one or the other of them to be on-call literally half of their lives.

Bottom Line:

For my call group to continue to function, we needed to come up with some form of relief.

We still feel the best care you are going to get if you get really sick is going to come from a doctor who already knows you well.

We think the hospital docs are excellent docs, but would prefer to take care of our own patients because it's important to us.

However, the times are changing around us and there aren't many of us left doing the full range of practice.

So, we want to try out a system where we're each on-call every fourth night and weekend for 3 weeks in a row, and then 3 weeks off.

During this 3-week off period, the hospital docs will be informed as to your medical history, surgeries and your medications.

Please let me know how you feel about this, and please let me know if you are in the hospital but feel that you would rather that I was seeing you there.

Again, this is a trial period from mid-July for about 3 months. At the end of it, we'll be seeing how it's working out for everyone involved especially our patients.

Happy July 4th!

Have a happy holiday celebrating our nation's independence with your friends and family.

In case it interests you, this link comments on a plain English contemporary reading of the Declaration of Independence. This link is a how-to on photographing fireworks displays.

Remember, that long stick coming out of the rocket is for staking it into the ground; it's not a handle... :-)